Download OMC Alumni Presentation 14/3/17

“My reading glasses don’t help…”
- a case of convergence insufficiency
in Parkinson’s Disease
OMC Alumni Presentation 20/3/17
DR DAMIEN LING (HMO)
DR LIONEL KOWAL
Case Overview
Mrs A, 75F
PMHx
• Parkinson’s Disease (dx 2006)
• Thyroidectomy for MNG (2006)
• Complicated by bilat recurrent laryngeal nerve palsies, required tracheostomy and laser arytenoidectomy
• Left vocal cord recovered; right remains paralysed
• Factor V Leiden
• DVTs: R) 2005, L) 2011, R) 2013
• On life-long warfarin
•
•
•
•
•
T2DM (diet)
HTN, Chol
Hysterectomy (2001)
Bilat hip OA
Scoliosis
Case Overview
Medications
•
•
•
•
•
•
Rasagiline 1mg mane
Madopar (levodopa/benserazide) 100mg/25mg x5/day
Pramipexole 1.5mg nocte
Thyroxine 100mcg mane
Warfarin
Vitamin D
SHx
• Lives in nursing home
• Retired nurse
Ocular Issues
1. Long-standing XT
• Present as a teenager, worse in last 4-5 years
2. Intermittent diplopia
• Was rarely, now >50% of the time
• Worse when tired, and when Parkinson’s medications wear off
3. Reading difficulty
• Needs to close one eye or shake head
4. Poor depth perception
Examination
• VA R 6/12(gls) L 6/9 (gls)
• Near: R N5 L N5
• IOP R 8 L 8
• Cover test: Distance XT 20^ to 38^ . Near XT 40^
• (both resolve constant diplopia)
• Ocular rotations MR -1 OU
• Left fundus: intorted. Right fundus: extorted.
Management Options?
Discussion – Visual Problems in PD
Evaluation
Parkinson’s Disease, n = 30
Controls, n = 31
p value
Surface irritation
19 (63.3)
9 (29.0)
0.007*
Diplopia
3 (10.0)
1 (3.2)
0.354
Difficulty reading
8 (26.7)
3 (9.7)
.106
Hallucinations
8 (26.7)
0 (0)
0.002*
Blepharospasm
4 (13.3)
0 (0)
0.002*
Dry eye
21 (70.0)
13 (41.9)
0.046*
Convergence insufficiency
7 (23.3)
6 (19.4)
0.704
Decreased near point
9 (30.0)
7 (22.6)
0.944
Decreased convergence
24 (80.0)
8 (25.8)
<0.001*
amplitudes
Values are no. (%). * Statistically significant
Biousse V. et al. Ophthalmologic features of Parkinson's disease. Neurology. 2004 Jan 27;62(2):177-80.
Discussion – CI in PD – common and
under-recognised
Prevalence
◦ 43.8% of participants with PD had a clinical diagnosis of CI, vs 16.3% without PD (p <0.001)
◦ Irving, E. L., Chriqui, E., Law, C., Kergoat, M.-J., Leclerc, B.-S., Panisset, M., Postuma, R. and Kergoat, H. (2016), Prevalence of
Convergence Insufficiency in Parkinson's Disease. Movmnt Disords Clncl Practice. doi: 10.1002/mdc3.12453
Management Options
Base-in prism glasses
• Patient already had 20^ BI in her glasses => persistent diplopia
• Cover test: required extra 12^ BI for distance, and extra 35^ BI for near
=> Total required: 32^ distance and 55^ near
Surgery
• High-risk for GA – previous airway issues, risk of oedema post-operatively with ETT
• Patient anxious re: GA or LA
Botox to LR
• ?Efficacy / duration of effect
Discussion – Management of CI in adults
• Non-surgical interventions
Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev. 2011 Mar
16;(3):CD006768
• In adults: effectiveness of interventions inconsistent. Only 1 trial at low-risk of bias
• Office-based vision therapy/orthoptics more effective than home-based exercises for improving clinical signs of CI, but does not
improve symptoms
• Surgical interventions
• Success rates vary from 18-92%
◦ MR resection(s) or LR recession(s)
◦ Choi DG & Rosenbaum Medial Rectus Resection(s) with Adjustable Suture for Intermittent Exotropia of the Convergence
Insufficiency Type. J AAPOS 2001;5:13-7.
◦ Retrospective study of 21 patients, follow-up 6 to 24 months (mean: 9.1)
◦ Reduced mean near exodeviation from 25.7^ to 3^ and distance from 11.4^ to -2^.
◦ Mean near-distance difference collapsed from 14.3^ pre-op to 5^ post-op
Discussion – Management of CI in adults
Botox injection to LR
1. Dawson E, Child C, Lee JP & Adams GG. The use of botulinum toxin in the management of convergence
insufficiency exotropia. J Am Assoc Pediatr Ophthalmol Strabismus (2012) 16: e13. (Poster Abstract)
◦ Retrospective analysis, 10 patients
◦ 8 had improvement in symptoms after 2-3 weeks; symptoms returned 3 months to 6 years
◦ 7 received maintenance injections (mean number of injections 4; range: 2 to 11)
Discussion – Management of CI in adults
Botox injection to LR
2. Saunte JP & Holmes JM. Sustained improvement of reading symptoms following botulinum toxin A injection for
convergence insufficiency. Strabismus. 2014 Sep;22(3):95-9.
◦ Retrospective analysis, 8 patients
◦ At 1 month, all patients had reduction of XT (median 9^, p=0.008). Reading improved in 7
◦ At 6 months, small reduction of XT persisted (median 4^, p=0.3), Reading improved in 8
◦ Beyond the duration pharmacological effect
◦ Adverse events:
◦ 2 patients developed moderate esodeviation greater at distance, resolved over months
◦ 1 developed 2mm ptosis, resolved in 4 weeks
◦ Subsequent correspondence with author (unpublished)
◦ Some patients have good effect with repeat injections every 4 – 12 months
◦ Others <1 month – nil repeat injections
Discussion – Management of CI in adults
3. Saunte JP & Christensen T. Improvement in reading symptoms following botulinum toxin A injection for
convergence insufficiency type intermittent exotropia. Acta Ophthalmologica. 2015 Aug; 93(5) e391-e392
◦
◦
◦
◦
Retrospective analysis, 5 patients with CI type IXT
At 1 month, all patients had reduction of XT (median 30^, p=0.25). Reading improved 2 of 3
At 6 months, all maintained reduction of XT (median 23^, p=0.06). Reading improved 5
At 12 months, reading improved in 3 of 4 patients
◦ Beyond the duration pharmacological effect
Progress
• September 2016 - Botox to RLR
• Significant improvement in diplopia and reading for 2/12
• Symptoms gradually returned to baseline
• March 2017 – Repeat Botox to RLR
• Follow-up pending
Progress
Right gaze
1 week
post
injection
2 weeks
post
injection
Primary position